Provider Demographics
NPI:1588747695
Name:PORTER, MICHAEL LEWIS (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEWIS
Last Name:PORTER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337A S IRBY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505
Mailing Address - Country:US
Mailing Address - Phone:843-667-0759
Mailing Address - Fax:843-667-0506
Practice Address - Street 1:1337A S IRBY ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505
Practice Address - Country:US
Practice Address - Phone:843-667-0759
Practice Address - Fax:843-667-0506
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6084183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC774367Medicaid
SC4213586OtherNABP